Hector Warnes’ response to Barry Blackwell’s response

I am grateful for Barry’s comments, which are indeed helping me to learn a new conceptual frame of reference in psychopathology not yet developed in the psychiatric literature. I think Barry is trying to fuse psychiatry and neurology, to which I have no objection, but he is taking the risk of throwing the baby out with the bath water. There have been many excellent studies on phantom limbs and misperception of hemiplegic limbs (estrangement, sensations that the limb does not belong to the patient, kinesthetic hallucination and so on).

I agree with Barry when he wrote that we do not really have a difference of opinion. I only objected to his using the word ‘agnosia’, not used before in psychopathology but mostly in neurology.

The reference given by Barry was the book written by Xavier F. Amador, an eminent clinical psychologist, who himself had a brother who was unaware of his severe mental disorder and ended up killing himself. Xavier Amador candidly spoke also of his own severe depressive episodes, which were accompanied by loss of awareness of being ill. An original paper by Amador, Flaum, Andreasen et al, was published in 1994. As we know, the team of Nancy Andreasen is highly respected all over the world. The authors reached the conclusion that about 50% of psychotics did not believe they were sick. Amador compares the patient’s ‘anosognosia’ (not agnosia as Barry used the word in regard with his patient with a manic episode) with the denial of the movements disorder (tardive dyskinesias) seen in patients with schizophrenia even those who were aware of being schizophrenics. Amador differentiates denial of illness (akin to a defense mechanism or psychological self-deception) from anosognosia, the latter he considers a frontal lobe dysfunction or pathology. Since this interesting study, which Barry has drawn to my attention, Amador has discovered over 200 publications regarding the lack of awareness of illness as a predictor of recovery, compliance with treatment and the amount of social support. I am sure that many patients would feel that they are at fault for their ‘lack of insight’ when it is really part of the constellation of their symptoms. A better word, used before insight was introduced in dynamic psychiatry, was the word discernment (dis, apart and cernere, to separate), to separate a thing or an event mentally from another or others; to perceive or recognize the difference. Measures of frontal lobe function and levels of unawareness of illness (Amador spoke of ‘pockets of insight’) implies that there is a cognitive deficit demonstrable with neuro-cognitive tests, functional brain imaging studies and frontal lobe hypoperfusion or hypometabolism studies.

Thanks to Barry I searched the publications on the topic and have chosen the following for further reading:

W. Bräutigam (1962), in a chapter written in Psychopathologie Heute celebrating Kurt Schneider’s 75th birthday (born in 1887) elaborates on the concept of consciousness and insight of illness during the evolution of the psychosis. In many cases, he noticed that it is “hoffnungslos, mit den Kranken zu argumentieren” (hopeless to argue with the patient) (p. 53).

Bräutigam (1962) distinguishes the lack of insight of the neurotic from that seen in psychosis. The former has to do with the insight into motives, needs, conflicts, contradictions and self- versus other persons images and reality experiences, while the latter has to do with being or not being sick or delusional in its capacity to delimit the sensus communis and the sensus privatus of reasoning and reality testing.

I am sure Barry has seen cases of Anorexia Nervosa (Magersucht or thinness addiction is the german word which better describes this condition), who were obviously ‘cadaveric’ and yet looking at themselves in the mirror would consider themselves as ‘fat’. This relentless pursuit of thinness to the point of denial of bodily appearance (Bruch called it delusional-like) is, in my opinion, a form of anosognosia (Griffin, Hennessy and Warnes 1978).